Please download this form before your pet's teeth cleaning or oral surgery. It will save you time and help us understand what level of care you want for your pet.

Date Client’s Name_________________ Pet’s NameSpecies _______Age Your pet is scheduled for a dental procedure. Once your pet is under anesthesia, the doctor and technician will perform an oral exam and carefully check the teeth and gums. During this exam, the Dr. may find one or more teeth that need to be extracted for health reasons. Based on the Dr.’s recommendations, the following services may be added to your invoice:Pre-Anesthetic Blood:Blood Count/Kidney Panel…$95. □ Accept□ DeclineEXTRACTION-Approximate Costs Deciduous (baby) Teeth Extractions-Canines (1 tooth)……………$12 Loose tooth extraction –Dental extraction I (1 tooth)………………..$7-$12 Single Root Extraction-Dental Extraction II ( 1 tooth)………………$12-$20 Molar Extraction-Surgical Extraction (1 tooth)……………………. .$20-$48DENTAL X-RAYS- Dental X-rays allow us to look beyond the obvious & better exam teeth and the supporting structures below the gumline. Viewing “inside” many times reveals hidden and often undiagnosed conditions. For that reason dental radiology is recommended for Grade 3 & 4 dentals and Resorbtive Lesions $12..Single tooth$65… Full Feline$75…Full K9 under 25 #$85...Full K9 Over 25# ___ Please Proceed as needed ____I do not authorize dental x-raysShould any unforeseen dental procedures be necessary and desirable in the veterinarian’s professional judgment:___I prefer that you proceed with all necessary dental procedures___I prefer to be called before any additional procedures, other than emergencies. If Icannot be reached, I authorize you to proceed with all necessary dental procedures.___ If I cannot be reached by phone, I do not authorize any unforeseen dental procedures. Your signature confirms that you have read this information and understand it. Thank you for your confidence in the care we provide for your pet. Client Signature________________________________________________________________ Today’s Phone numbers_______________________ Cell__________________________